Web‐based support services to help prevent suicide in young people and students: A mixed‐methods, user‐informed review of characteristics and effective elements

Abstract The online world may provide an alternative means to engage young people and students with suicidal feelings, who are typically reluctant to seek help. We aimed to map, characterise and obtain user evaluation of current online suicide support for this group in order to assess the usefulness of current provision and how it may be improved. We conducted a mixed‐methods study, comprised of an internet search, content analysis of site features and qualitative interviews with site users: 9 young people and 4 general practitioners. Data collection took place in 2019 and 2020 in the UK. Young people participants were recruited through the well‐being networks of a large University in South‐West England and via a national young person's mental health app. General practitioners were recruited locally through professional networks. We identified a wide range of easily accessible online support, including examples of interactive services, such as live chat and text messaging, but a lack of support that is both suicide‐specific and young adult‐specific, and an absence of online suicide or mental health crisis support services tailored specifically for students. Qualitative data showed that clarity, brevity and immediacy are the most important facets of engaging crisis help for young people, and that young people may prefer to use text‐based rather than verbal forms of communication when seeking help. Few services provided access to active peer support, outside of lived‐experience stories, which were evaluated as both valuable and potentially harmful. There is a need to further develop tailored suicide specific online crisis support for young people and students, which is able to ‘speak to’ their age‐specific needs and preferences. While lived experience may provide a valuable means of supporting young audiences, caution is required since this may have unintended negative consequences and further research is needed to understand the safe framing of such material.


| INTRODUC TI ON
Suicide is a leading cause of death amongst young people (YP) worldwide (Bilsen, 2018), but responding to this problem is challenging because YP are often reluctant to seek help (Michelmore & Hindley, 2012). The mental health of university of students has also been highlighted as a growing issue of concern in the UK, with rates of suicide increasing amongst this group  alongside reported low levels of help-seeking (Knipe et al., 2018).
It has been suggested that the online world may provide an alternative means of delivering support (Robinson et al., 2017;Rowe et al., 2018;Seward & Harris, 2016). Use of the internet for purposes relating to thoughts of suicide is common amongst YP experiencing suicidal feelings (Mars et al., 2015) and may include seeking help, information or contact with like-minded peers. An increasing range of suicide prevention material is available online (Thornton et al., 2017) yet seeking help online may also present risks (Marchant et al., 2017). For instance, Biddle et al. (2018) found online activity can maintain or exacerbate suicidal feelings since, even where initially seeking help online, users typically 'stumble' upon graphic content such as information about methods and display a tendency to flit between prevention and pro-suicide content as mood lowers. Similarly, online interactions may espouse reinforcing attitudes towards self-harm.
Adding to such difficulties, online services do not always meet the needs of users in crisis (Biddle et al., 2020). Evidence indicates that service features considered most helpful include immediacy of response in situ, and the provision of lived-experience stories of self-harm and interactive content, such as live chat, while signposting to external services (especially when requiring the user to make additional phone call or contacts) is less acceptable (Biddle et al., 2020). However, no studies have reported how commonly these features are provided by existing online services and few have explored users' perceptions of online help. We aimed to address these knowledge gaps via a comprehensive mapping exercise and in-depth interviews with service users in order to provide a basis for improving online service provision for YP experiencing suicidal crisis.

| MATERIAL AND ME THODS
A sequential cross-sectional mixed-methods design was adopted.
Ethical approval was obtained from the University of Bristol Faculty of Health Sciences Research Ethics Committee (ref: 92982). The study involved three phases:

| Service mapping
We conducted an internet search to map existing suicide support provision for YP and students. We focused on services immediately accessible in a moment of crisis and therefore excluded Apps or social media requiring users to 'sign up' before accessing support.
The search comprised 18 search terms (Table 1) replicating a broad range of possible search strategies that might be used by YP and students specifically searching the internet for support during times of severe mental distress or suicidal feelings. The selected terms were informed by previous research (Biddle et al., 2018) and autocomplete search suggestions.
Terms were entered into the two most commonly used search engines in the UK in 2019 when the searches were conducted: Google and Bing, which jointly held 96.8% of the UK market share (www.stati What is known about this topic?
• Young people are often reluctant to seek help for suicidal feelings from face-to-face services.
• Online mental health services do not always meet the needs or preferences of users in crisis.

What this paper adds?
• There is a lack of suicide-specific online support for young people and students tailored to their age-specific needs and preferences.
• When engaging with online services, young people seek immediate navigation to interactive support options and brevity in provision of psychoeducational content.
• Participants expressed a preference for text-based live digital help offerings. sta.com). Searches were run on a desktop computer and mobile phone to capture disparities produced by searching on differing devices. To identify sites specifically targetting YP, each term was re-run prefaced first with 'young person' and second with 'student', for example 'suicide help', 'young person suicide help', 'student suicide help'.
Each term was thus entered three times into each search engine and into both devices, resulting in a total of 216 searches. Consistent with other studies (Biddle et al., 2016), we retrieved the first 10 hits from each search (Figure 1).
Hits were classified by type using a coding frame. RC, RRZ and LB independently double-coded then discussed a sub-sample of hits.
Existing coding categories were then refined, and new categories were created. This was repeated three times to establish a robust coding frame. RC and RRZ independently coded the remaining hits, meeting to discuss disagreements and refer uncertain cases to LB. A high inter-rater agreement rate of 80% was achieved, with only 5% of disagreements requiring arbitration.

| Content analysis
Hits coded as support/prevention services or as static support information pages were considered to be of most immediate relevance to the study aims and progressed to further content analysis (categories A and B, Table 2). Either a basic descriptive summary or a detailed analysis of website content was produced; detailed analysis being restricted to interactive services primarily dedicated to providing suicide and/or mental health prevention as these aligned most directly to our research aim. Detailed analysis, guided by a proforma, captured the key features of each service: types of support provided; resources (including downloadable materials); audience served (including diversity); strategies to communicate with users; and signposting to other resources. Analysis involved navigating away from landing pages to explore the whole site, including text, images and media.

| Qualitative interviews with site users (YP and general practitioners)
In-depth interviews were conducted with YPs and general practitioners (GPs) to gain evaluation of the format and content of online support services, and capture experiences of using, or referring to, such services. YPs were aged 16-25 years, English-speaking and current/previous users of online crisis services. A convenience sampling approach was used to recruit participants by advertising through the wellbeing services of a large University in Southwest England and a UK-based young person's mental health app: www.meetoo.help. We purposively sought students, recognising possible unique needs of this sub-population relating to suicide prevention. GPs were English speaking and recruited via existing professional networks.
Interviews were semi-structured and conducted via secure online video conferencing in 2020. Their length ranged from 22 min to just over an hour, with most lasting between 40 and 60 min. All participants were provided with a participant information sheet before commencing and gave informed consent. Interviews were audio recorded, then transcribed by a university-approved transcriber in accordance with data protection regulations. Data collection and analysis were concurrent to ensure knowledge developed incrementally. A topic guide ensured our research aim was explored with each participant. This included broad headings and prompts relating to experiences of seeking online help during a crisis; the relationship between online and offline help; and evaluations of current online help content. Participants were also shown and asked to comment on two online service websites frequently retrieved in our search.
However, participants were encouraged to talk freely identifying what they considered pertinent. The topic guide was revised to incorporate emerging themes.
Transcripts were coded by RC with a sample also independently coded by LB to ensure reliability. Coding involved identifying concepts and themes common across both participant groups and gathering supporting quotes. Content categories were developed within F I G U R E 1 Search strategy the themes through a process of independent analysis and then discussion between RC and LB. These captured the main considerations in relation to each theme were raised by YPs and GPs.

| Service mapping
We retrieved 2160 hits in total. With duplicates, unavailable links and hits not relevant to suicide or mental health removed, 232 unique hits remained (Table 2).
Just over half of the unique hits (n = 118, 51%) were deemed to provide some explicit support for individuals experiencing mental health or suicidal crisis. Of these, the largest category (n = 57, 25%) was the online offering of larger support/prevention services-'category A'. Thirty-five 'A category' hits were provided by charity services (15% of all hits), 7 (3%) by statutory (NHS) health services, 13 (6%) by Universities whose services were available only to students at the particular institution, and 2 (1%) were private (psychiatry/CBT/counselling) services. The five most frequently retrieved hits (before removing duplicates) were all 'A category' sites. Other supportive hits were webpages providing static support information, reassurance or advice, but no contactable service beyond signposting to other organisations ('category B': n = 45, 19%); or pages comprised of signposting only, offering no significant in situ support ('category C': n = 16, 7%). A further small group of sites provided information for those supporting an individual with suicidal thoughts ('category D': n = 26, 11%).
The remaining 88 sites (40%) provided general information or commentary about suicide without specific focus on help or support, although reference to this could feature. These included academic/policy sites (n = 24, 10%), news media reports (n = 26, 11%) and user-generated pages such as chatrooms or forums (n = 9, 4%).
Only one such hit was an entire site dedicated to suicide and while not overtly pro-suicide, substantial information was contained about suicide methods. This site appeared in 14 (7%) searches.

| Content analysis of support/prevention services ('A category' hits)
Thirty-five hits met the criteria for detailed content analysis-that is, they were deemed to constitute a dedicated support service and not merely static information. This was indicated by the site providing access to its own connected service components such as a phoneline or instant messaging. These were all 'A category' hits, linked to charitable services. One or more of these services appeared in 86.6% of searches. The majority were UK (n = 20) or USA (n = 11) based, with the remainder from Australia (n = 3) and Canada (n = 1).
Content analysis of statutory, private and university services (also A category) was limited to basic descriptive summaries (reported below) since these were not wholly dedicated to providing support for mental health/suicide. Findings from detailed content analysis are summarised in Table 3.

Focus and target audience
We identified 11 suicide-specific online help services. The remainder covered mental health more generally while referring to suicide. Most of the latter were pitched at a general audience, though 10 were YP specific. Notably, only 1 service was both young person and suicide specific (this appeared in less than half [40.7%] our searches), and no student-specific suicide or mental health crisis services were found.
Most sites were deemed inclusive to a wide range of users, and some provided information for specific groups. Specialist LGBTQ support was provided by four sites, two sites provided gender-sensitive information, one was tailored towards those of a Christian faith, and three provided support for deaf users.
Some sites from the US/Australia offered support for First Nations people and Native Americans, and for disaster survivors. Images shown represented diversity; 17 sites included a range of ethnicities, 11 showed a range of different ages, and 10 showed images of different genders.

Help features provided at the service sites
The most common type of help provided was psychoeducation about mental health. Twenty-one sites provided suicide-specific information. Only one did not provide any such material, but instead emphasised the importance of reaching out for immediate help.
Educational material typically incorporated a range of elements.
Almost all sites highlighted the importance of seeking help. Over half offered advice and information on how to help someone else experiencing suicidal feelings. Approximately half strove to educate users about how to recognise warning signs associated with suicidality, and how to respond in a healthy way. Some included information on potential risk factors and possible causes of suicidal feelings. The presentational style varied but typically consisted of at least one page of material, mostly organised by sub-headings and sometimes using bullet-pointed text. The information presented by three sites was densely packed and detailed. Only two sites delivered information using videos aimed at someone who is suicidal.
Over half the sites (n = 19) offered tips or tools for self-help.
The scope of these ranged from self-care around general mental health and wellness to more suicide-specific advice; and from downloadable resources such as leaflets, factsheets and information on 'how to cope' (which were an extension to psychosocial education), to relaxation exercises and advice/tools for creating a suicide safety plan. Seven sites provided a downloadable crisis/ safety plan template.
Half the sites (n = 17) included lived-experience accounts of suicidal feelings as a means of communicating support information. Typically, these were framed as stories of 'hope and recovery' and several provided explicit accounts of people having successfully reached out for help, often emphasising the value of the support they had received from that service during a crisis. Universities' own offline wellbeing services. One university page featured lived experience videos and blog/vlog links. Private services (n = 2) were not suicide or young person-specific and provided some psychoeducational content and minimal signposting. Static support sites (category B) were exclusively composed of psychosocial education and signposting. In all instances, charity services were chiefly signposted to as the main source of online suicide support, reaffirming the focus of our detailed content analysis on these services.

| Qualitative findings
Nine YP (3 male, 6 female) and 4 GPs (3 female, 1 male) were interviewed after responding to advertisements for research participants. YP had a mean age of 19 years, two were university students and all but one had sought online help for mental health difficulties.
Some had also sought offline healthcare, for instance from primary or secondary care. All shared their views on the likely value of online help in times of suicide or mental health crisis. GPs were experienced in providing mental healthcare to YP, all with over 10 years of experience, and two specialised in student mental health.

| DISCUSS ION
This study mapped online help provision for YP and students experiencing acute mental or suicidal crises. We identified a wide range of easily accessible online support, either focusing or touching upon suicidal thoughts or behaviours and ranging from signposting and static information to interactive services. Fifteen per cent of unique hits were prevention services, wholly dedicated to providing mental health or support for suicidal crises. These amounted to 35 charity services, of which at least one appeared in 87% of our searches, and four were amongst the five most frequently retrieved sites.
Our findings show an individual entering basic suicide-related help search terms (e.g. suicide help) also will commonly be directed to general discourse around suicide, which on occasion could trigger harmful behaviour in vulnerable individuals. This included one site containing detailed information about suicide methods, retrieved in 7% of searches.
Content analysis of dedicated interactive online crisis support services revealed that while there were several mental health services aimed at YP, only one was suicide specific, and none were dedicated to students as a specific population group. However, in qualitative interviews, YP and GPs stressed the importance of ageappropriate support to meet users' needs and secure engagement.
Provision of psychoeducational information was the most common service feature, offered by almost all services. Self-care advice was also common with several services providing downloadable documents, such as safety plan templates. Qualitative findings indicated that YP preferred psychoeducational material to be filterable, brief and clear because lengthy information was described as overwhelming and lacked immediacy.
Interview participants deemed the most effective services as those whose interactive help options were displayed clearly and immediately-for example, on a running banner or on the website homepage-so they could be accessed as the first line of response without having to read other information. It was highlighted that crisis support options should be provided in a range of formats, though there was a strong preference amongst participants in this study for written (e.g. webchat and text), rather than verbal (e.g. phoneline), forms of communication when seeking help online. Nineteen of the services provided online chat and/or text messaging, and one of these services was reached in 57.9% of our searches.
Over half the services utilised lived-experience accounts as a means of engaging users and delivering support messaging. While the YP interviewed were largely positive about this, perceiving it to offer reassurance, hope, interpretation of symptoms, and validation, a potential for unintended harm was also flagged. Only a few services offered access to active peer support.
It is asserted that the internet can contribute to suicide prevention (Luxton et al., 2012). Our study has provided the first comprehensive mapping and characterisation of current online provision of help for YP and students experiencing suicidal crises and has explored the prevalence of features suggested by other research (Biddle et al., 2020) as most likely to meet the needs of distressed users. While identifying examples of valuable online support, we found a lack of opportunities for peer support and support that is both suicide-specific and young adult-specific. This is notable since research indicates online users with suicidal thoughts have unique help needs that are not well met by general mental health sites (Biddle et al., 2020). Moreover, we found an absence of suicide or online mental health crisis support services tailored specifically for students despite growing concern about the mental health of YP in higher education (Reavley & Jorm, 2010). As well as aligning with current understanding about preferences for online help, our qualitative findings also provide additional insights into engaging ways of presenting information and making sites navigable and YP's preferences around the format of 'live' online help offerings. Participants' reflections on lived-experience content are pertinent to existing debate about the benefits of such material (Till et al., 2017) and reinforce the need for research able to specify ingredients of safe and supportive lived experienced accounts.

| Strengths and limitations
Our mixed-methods design allowed us to quantify the features of online suicide crisis provision while simultaneously providing a more nuanced understanding of how these are experienced by users.
Interview participants were recruited from diverse settings to increase the experiences represented. The YP drew on experiences of acute mental distress and online service use and their accounts were triangulated with those of GPs with expertise in adolescent and student mental health. This approach furthers previous work, which has sought participant views via survey methods (Bell et al., 2018;Harris et al., 2009). While our participants provided rich accounts with extensive (often longitudinal) narratives of seeking online support for mental distress and consistent themes were obtained within our analysis, our sample size was small and further research with purposive sampling would be beneficial to examine transferability of findings.
Our study was conducted in England and whilst not limited to UK-specific services, this may have influenced our search output and we did not seek to incorporate international perspectives about online service provision. The online world constantly evolves and responds to the changing social context. Our mapping provides a cross-sectional view and some changes to online provision are likely to have occurred over time in the same way that accessibility of pro-suicide content has also been observed to change (Biddle et al., 2016). For instance, upon briefly revisiting some of the sites identified, we observed provision of additional interactive crisis support options during the COVID-19 pandemic: one of these was student specific. We also noted changes to the images on several sites

| CON CLUS IONS
Our study identifies a need to develop online crisis support that is both young person and suicide-specific and provides essential information to aid the design of such services. Our qualitative data highlight clarity, brevity and immediacy as the most important facets of engaging crisis help for YP. This should include information and advice specifically tailored towards this age group since YP may be discouraged from engaging with services that do not 'speak to' their age-specific needs and preferences, or where they feel that their difficulties are not validated by the forms of support available. To address YP's desire for quick responses, ease of navigation should be improved by placing crisis support options upfront and making these immediately visible while ensuring brevity in the provision of psychoeducational content. Providing more opportunities for active peer support may also help to address the desire expressed by YP to interact with others having similar experiences, and online crisis services could provide the ideal forum for ensuring this is offered in a moderated environment. The growth of live digital help offerings such as instant messaging and texting is a welcome development, which speaks to our participants' preferences for written rather than verbal forms of crisis help and might usefully be expanded, though the needs of users with low literacy should also be remembered.
Such a service was reached in only just over half (57.9%) of our searches, indicating that a potentially valuable opportunity for more effective suicide prevention is still being missed.

ACK N OWLED G EM ENTS
We thank the study participants who spoke about their experiences and Alison Golden-Wright, Mike Bell and the MeeToo mental health app for assistance with recruitment. MeeToo is a free, anonymous, 100% pre-moderated peer support app for young people aged 11-25. MeeToo contains an extensive directory of interactive crisis support and self-help tools and is part of the NHS apps library. This research was supported by the Elizabeth Blackwell Institute, University of Bristol, and funded in whole, or in part, by the Wellcome Trust [204813/Z/16/Z]. For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission.
The research funder and sponsor played no role in study design, collection or interpretation of data, or preparation of the manuscript.

CO N FLI C T O F I NTE R E S T
None declared.

AUTH O R CO NTR I B UTI O N S
LB and RC conceived of and designed the study. RC and RRZ ran internet searches and carried out the content analysis with support from LB. RRZ conducted quantitative analysis. RC collected the qualitative data and led analysis with support from LB. All authors participated in study development meetings. LB and RC prepared the manuscript. RRZ and PM commented on manuscript drafts. All authors read and agreed the final manuscript.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.